Recognising domestic violence in pregnancy

Recognising
domestic violence
in pregnancy

Joanna Cook1 & Susan Bewley2

1 Clinical Research Fellow, Imperial College London
2 Professor of Complex Obstetrics, King’s College London

March 2015 © 2015 The Health Foundation

Recognise the risks of violence Strategies for routine enquiry
at various stages of pregnancy
A clinician who embeds DV screening into
Domestic violence (DV) is common most consultations is more likely to appear
and is reported by up to 31% of women confident, comfortable and able to help.
in the UK;1 worryingly the abuse often It is important to make yourself aware
commences or escalates in pregnancy and of local referral pathways and specialist
the post-natal period.2 DV is a pattern of services such as your safeguarding midwife
psychological, physical or sexual assaults, or consultant; in addition, the Freephone
which increases a pregnant woman’s risk of 24 Hour National Domestic Violence
multiple and diverse adverse outcomes. A Helpline, run in partnership between
pregnant woman experiencing DV is more Women’s Aid and Refuge, is a useful
likely to request termination and repeated resource (Figure 1).
terminations, seek to end a previously Many women are accompanied to
wanted pregnancy or spontaneously antenatal appointments by their partners,
miscarry.3 If the pregnancy continues, she friends or family members, but it is
is more likely to experience antepartum important to briefly see each woman alone.
haemorrhage, chorioamnionitis and Normalising any request to see women
preterm labour.2 Her baby is more likely to alone can be explained as part of routine
be of lower birth weight or to be stillborn.4 practise. It may not be safe to directly
Women experiencing violence are also question all women about DV, especially if
at greater risk of pelvic pain, sexually you are unable to see a woman by herself.
transmitted and urinary tract infections.5 If you are worried, remember to pass on
The sequelae of a violent relationship can, your concerns to other staff that will see
of course, extend in to other, non-clinical her in future. Ensure that you are in a
aspects of a pregnant woman’s life: She private space, with soundproof walls, not
can be at greater risk of abusing drugs just curtains. Never use family translators
and alcohol,6 smoking,7 chronic stress when you are questioning a woman about
and there may be sibling-child protection abuse; her safety and confidentiality may
concerns. As such, healthcare professionals both be compromised.
may feel impotent or overwhelmed. They Initial ‘open questions’ such as ‘how are
may avoid encouraging the disclosure of things at home?’ or ‘are things OK at
abuse, even when they have cause to be home with your partner and family?’ can
suspicious. However, it is important to be used to allow a woman to describe
emphasise that the role of the doctor or her circumstances. More direct questions
midwife is not to ‘cure’ all the complex can follow, such as ‘does anyone try to
consequences of abuse, but to cultivate control or humiliate you?’, ‘are you afraid
a trusting and confidential relationship of anyone at home?’, or ‘has someone
so that women can disclose DV and be hurt you at home?’8 You may want to
directed to other specialist agencies which further justify your questions: ‘Over one
can then provide individualised support in four women experiences violence or
and assistance. The healthcare setting can undermining at home at some stage – so
be a safe location for disclosing DV and it’s important that I ask everyone if they
supporting intervention; almost all women feel safe.’
interact with healthcare, there are strong
cultures of confidentiality and staff are
usually kind and trustworthy.

Recognising domestic violence in pregnancy 2

Sometimes pregnant women will present from her. These barriers are complex, but
with minor, often recurring symptoms, you can initiate systemic changes to help
which cannot easily be medically overcome them. Promoting a culture of
explained. Whilst these complaints may confidentiality in your workplace and
be part of the physiological changes of publicising this commitment to your
pregnancy (abdominal discomfort, vaginal patients in posters, leaflets and your
discharge, frequency) they may also be a professional websites can be helpful. Be
presentation of past or current abuse. You critical of your consultation style and
may want to acknowledge the potential ask colleagues to sit-in on your clinics
connection: ‘Some women with these and provide feedback on your listening
symptoms may be at risk of suffering skills and how you may come across
abuse from a partner or other adult. Is to more vulnerable women. It is also
that happening to you?’ Other behaviours, important to maintain good links with
like persistent smoking in pregnancy, community midwives and health visitors
booking late, missing appointments or who may have more insight in to the social
self-discharging from hospital should raise situations of your patients.
your suspicions.9 Similarly, injuries to the
face, neck, breasts, abdomen and inner Responses to reduce risk
thighs are less likely to be accidental10 and
should prompt private questioning. If a pregnant woman discloses DV to you
A woman will not discuss abuse until she there are several simple strategies you can
has assessed your potential reaction and employ to reduce the risk of further harm.
she should never feel under pressure to As a person in a position of authority, it
disclose. Enquiring about abuse can be is important that you acknowledge that
valuable, even if the response is negative. psychological, physical or sexual abuse
Such questions convey that you feel DV is unacceptable and a crime. Showing
is an important healthcare issue, that you great respect and concern for pregnant
are prepared to listen and know where to women in abusive relationships is a simple
obtain further support. You may want to intervention that can increase self-esteem
offer referral information anyway - ‘here and validate their disclosure. Repeatedly
is a number you can call if you or a friend reiterate that it is not her fault and that
ever have any concerns.’ Even if the woman no one deserves to be treated this way.
is not experiencing abuse, she may discuss Statements such as ‘everybody deserves to
the topic with friends who are, thereby feel safe at home’ and ‘abuse is common
indirectly assisting them in seeking help in all kinds of relationships and it tends to
for themselves. continue’ can support women to pursue
Some women subjected to DV will still positive change.
not reveal it when asked. This can be Women should be informed about local
because she falsely perceives the abuse specialist services and given the local
to be insignificant or her fault. She may or national domestic violence helpline
feel shame and be concerned that her numbers. Be careful not to insist she takes
confidentiality will not be maintained. written advice away, as this may further
She may fear for her own safety if she compromise her safety if seen by family
discloses, or that Social Services will members. Warn her that the severity of
become involved and take her child(ren) abuse often worsens in pregnancy or in

Recognising domestic violence in pregnancy 3

the post-natal period. Those experiencing Figure 1: Poster advertising the freephone
abuse are experts in their own care and 24 Hour National Domestic Violence
will have insights into their own safety that helpline, run in partnership between
you will not possess. You should involve Women’s Aid and Refuge. This service is
the woman in any response to external staffed 24 hours/day and can assist women
agencies (DV advocates, the Police and in accessing local services and sources of
Social Services). Make her aware of your support. Women’s Aid also run training
commitment to confidentiality and its programmes specifically for nurses,
limits. Ask how you (or other agencies) midwives or health visitors.
can safely contact her again without
arousing the perpetrator’s suspicion.
Never make any written reference to DV
in ‘handheld’ maternity notes as this may
reveal a woman’s disclosure to family
members and put her at greater risk of
escalating abuse. Involve the woman
in your record keeping and make an
objective, contemporaneous account of the
abuse in the woman’s confidential medical
records. Explain that this may be accessed,
with her permission, in any future legal
proceedings. Some women will not want
to involve the police and the reasons for
this should be explored. Possibly she feels
the DV is not significant – which may be a
coping strategy, or alternatively involving
the police may further compromise her
safety and so be detrimental at that specific
point in time.
The safety of the unborn child and any
other children in the household should
be briefly explored. Try to emphasise to
women that social services’ central role
is to support parents to protect their
children, not to separate families.
Finally, aim to always practise within
your expertise – address the medical
consequences of abuse and explain that
DV is a risk factor for poor health. But
do not be tempted to give personal,
immigration, housing, legal or social
care advice. You may unintentionally
mislead your patient and undermine
her trust in your relationship. A local
safeguarding specialist or DV advocate is
far better placed to explain the options and
assistance available.

Recognising domestic violence in pregnancy 4

Further reading

Bewley, S & Welch, J (eds) 2014, ABC of domestic
and sexual violence, London, Wiley Blackwell

Domestic violence and abuse: how health services,
social care and the organisations they work with can
respond effectively
http://www.nice.org.uk/guidance/ph50

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